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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804143
Report Date: 04/09/2025
Date Signed: 04/09/2025 05:36:54 PM

Document Has Been Signed on 04/09/2025 05:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SENIOR CARE LIVINGFACILITY NUMBER:
496804143
ADMINISTRATOR/
DIRECTOR:		SORENSEN, JANINEFACILITY TYPE:
740
ADDRESS:1960 DENNIS LANETELEPHONE:
(707) 852-5043
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
04/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Janine Sorenson-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 4/9/25 at approximately 2:00pm, and met with Administrator Janine Sorenson.. Caregivers notified Licensee/Administrator that the LPA had arrived to conduct an inspection.

There currently are six (6) residents in care. LPA observed two caregivers on duty.

LPA reviewed six (6) resident files. All files were complete.

LPA reviewed five (5) staff files. LPA reviewed staff training. LPA reviewed staff's first aid and CPR certifications. All staff have criminal record clearance as required.

Facility has a fire clearance approval for 6 non-ambulatory of which 1 may be bedridden, in room #2 only. Fire extinguishers were serviced and tagged as required. Emergency fire & disaster drills are conducted as required.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for three(3)residents. Facility has a required infection control plan. Facility has an emergency and disaster plan as required. Facility does have a generator for emergencies if needed. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements.

Hot water was measured at 113.3 degrees Fahrenheit. The exits were cleared and unobstructed. Food supply was sufficient. Sufficient furnishings throughout the facility. Sufficient lighting in all resident rooms, bathrooms, and common areas.
Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SENIOR CARE LIVING
FACILITY NUMBER: 496804143
VISIT DATE: 04/09/2025
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Sufficient supply of linens, cleaners/disinfectants, and paper products. All medications were locked and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. Bathrooms had grab bars and non-slip mats and/or shower flooring for resident use.

LPA discussed the updated/changes in regulations with Administrator Janine Sorenson. LPA emailed the Departments PIN ASC- #24-09, regarding the regulation updates, to the Licensee/Administrator Ami Kumar and Janine Sorenson, Administrator.

LPA are requesting the following documents be updated and submitted to CCL by 5/9//2025:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610 - Emergency Disaster Plan-update if needed-submit if changes
Copy of Current Liability Insurance
Copy of current Administrator Certificate
Copy of updated Infection Control Plan- update if needed- submit if changes

The following deficiency (s) was observed by the LPA during the inspection:
Per LPA observation, there were two uncovered bowls of pureed food and/or what looked like soup, a plate with food not fully covered by the foil on it, and a large, uncovered blender jar filled with food to be pureed. This deficiency will be cited, 87555(b)(9) General Food Service Requirements- The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service, see LIC809D.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.



Exit interview conducted with Administrator Janine Sorenson.
Appeal Rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/09/2025 05:36 PM - It Cannot Be Edited


Created By: Dina Alviso On 04/09/2025 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SENIOR CARE LIVING
FACILITY NUMBER: 496804143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(9)
87555(b)(9) General Food Service Requirements-The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA observation, there were two uncovered bowls of pureed food and/or what looked like soup, a plate with food not fully covered by the foil on it, and a large, uncovered blender jar filled with food to be pureed, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2025
Plan of Correction
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Licensee to ensure all food stored in the refrigerator is stored/appropriately covered using procedures which protect the safety, acceptability and nutritive values of the food items; Hold an in-service with staff regarding “Food Service, including Food Storage Procedures” with all staff. Follow-up with a plan of facility’s future compliance with this regulation, and proof of training due 4/18/25. POC due 4/10/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
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